Leprosy – An Old Threat: Frequently Missedbsmedicine.org/congress/2015/Dr._Shafiqul_Bari.pdf · Scenario •A 30-year-old rickshaw puller presented with gradually developing tingling

Leprosy – An Old Threat: Frequently Missed

Md. Shafiqul Bari

Associate professor (Medicine)

Sylhet MAG Osmani Medical College

Scenario

• A 30-year-old rickshaw puller presented with gradually developing tingling and numbness of hands and feet

Thickened ulnar nerve

History

• The term Leprosy is derived from the Greek word “Lepros” which means “Scaly”.

• The name “Kustha” was derived from “Kushnati” which means “eating away” in Sanskrit.

• Sufferers were regarded as dead, and segregated from the society.

• 1873 - Dr. Armuer Hansen discovered that a microorganism (Mycobacterium leprae) is responsible for the disease

• 1991 - World Health Assembly targeted Elimination Leprosy as a public health problem.

History of treatment

• 1940s - Dapsone replaced Chaulmoogra oil.

• 1981 - WHO introduced MDT for all cases of Leprosy

Registered prevalence of leprosy reported by WHO,

2012

• Total – 189 018 (0.33)

• SEAR – 125 167 (0.68)

Global trends in the detection of new cases of leprosy, 2005–2012

Trends in the detection of leprosy (2005 – 2012) in Bangladesh

Leprosy prevalence in Bangladesh

• 1991 – 13.6/10 000 population

• 2012 – 0.29/10,000 population

Below one per 10,000 means the disease has been eliminated and no longer represents a major public health concern

Milestones of achievement in Bangladesh

• 1985 - Introduction of MDT in 120 high

endemic upazilas

• 1993 - Intensification of leprosy elimination activities through integration of the leprosy control services into the general health services

• 1998 - Achievement of elimination goal at national level.

Endemic zones

• Nilphamari

• Panchagarh

• Gaibandha

• Bandarban

• Khagrachari

Clinical aspects

• Cardinal Signs of Leprosy

Definite loss of sensation in a pale or reddish skin

A thickened or enlarged peripheral nerve, with loss of sensation and/or weakness of the muscles supplied by that nerve

The presence of AFB in a slit skin smear

Differential diagnosis of skin lesion

• Some signs, frequent in skin diseases, are unusual in Leprosy,

if the lesions are itching

if they are scaling

if they are hyper-pigmented

if they are inflamed

Look for other skin disease

• Flat lesion:

Birth mark

Vitiligo and leucoderma

Nutritional dyschromia

Ringworm

Pityriasis versicolor

• Raised lesions: papules, plaques

Psoriasis

• Raised lesions: nodules or swellings

PKDL

Lupus Vulgaris

Neurofibromatosis

NEGATIVE SKINSMEAR FOR AFB = IMPOSSIBLE IN REAL LEPROSY NODULE

Differential diagnosis of foot ulcer

• Diabetic foot-ulcers

• Buergers disease

• Meningomyelocoele or spina bifida

Differential diagnosis of deformity

• In any cases presenting with acquired deformities we should keep leprosy in differential diagnosis

• We should look for nerve thickening, definite sensory loss and cutaneous lesion

• Differential diagnosis will need to be carried out with other conditions like trauma, other type of palsy etc.

• Definite confirmation of leprosy may need Nerve Conduction Study, skin or nerve biopsy and PCR technique to detect leprosy infection in certain difficult to diagnose cases.

Reactions in leprosy

• Reversal Reaction (or Type 1) and ENL (or Type 2)

• Both the types of reactions can occur before the start of treatment, during treatment, or after the treatment has been completed.

• Both types can be divided into mild or severe.

• Lepra reactions are usually diagnosed by clinical examination only

• Some cases develop signs of nerve damage (neuritis) without the obvious changes in skin lesions.

Type I (Reversal reaction) Type II (ENL)

Type IV hypersensitivity reaction Type III hypersensitivity reaction

Borderline group i.e. in unstable types like BT.BB.BL.

Seen in MB cases only (BL & LL type)

Existing skin lesions suddenly become inflammed Red, painful, tender, sub cutaneous nodules .

Nerves close to skin may be enlarged, tender and painful (neuritis) with loss of nerve function (loss of sensation and muscle weakness) and may appear suddenly or rapidly.

Nerves may be affected but not as common or severe as in Type 1

Other organs - Not affected Other organs like eyes, testis, and kidneys may be affected

General symptoms - Not common Fever, joints pain, red eyes with watering

Key message

• Although the majority of leprosy patients have straightforward skin lesions which are easy to see, experienced workers know that there is a great variety in the skin lesions of leprosy.

• Some skin lesions are very diffuse and difficult to distinguish from normal skin: in these cases the other symptoms and signs become important.

When should leprosy be suspected?

• Typical or atypical skin lesion

• Loss, or decrease, of feeling in the skin lesion

• Numbness or tingling of the hands or feet

• Weakness of the hands, feet or eyelids

• Painful or tender nerves or thickened nerve

• Swellings or lumps in the face or earlobes

• Painless wounds or burns on the hands or feet

• Acquired deformity of hands and feet